Technology, affordability and patient satisfaction mean in-home health care solutions could revolutionize medical care for older Americans
By Beth Baker
Jim Petersen, 83, who lives alone in an assisted living community outside Denver, recently had pneumonia. But rather than be admitted to the hospital, he was offered another choice: hospital-level treatment in his home.
Petersen didn’t hesitate. “In plain English, there’s no place like home,” he says. “You can get good care in a hospital, but you never sleep really good.”
In the wake of the COVID-19 pandemic, a growing number of older patients like Petersen are more eager than ever to avoid hospitalization. Depending on their condition, many can receive the full complement of professional services in their home, paid for by Medicare as if they were in the hospital.
In Petersen’s case, nurses and physician assistants came to his home to monitor him and administer antibiotics. “With the technology today, they can take x-rays and EKGs and blood work right here in my apartment,” he says. “They were just great. I stayed here and recovered.”
“COVID has provided tailwinds to pushing care inside the home. The market is demanding it.”
His physician, Dr. Manny Diaz, used to work in a hospital. But then he was offered the position of medical director with Advanced Care-Denver, an arm of DispatchHealth. “The opportunity that I believe will be the future of health care, moving as much as we can effectively and safely into people’s homes to provide comfort at a lower cost, was something I couldn’t pass up,” Diaz says.
In-home visits “invert the relationship” between doctor and patient, he adds. In a hospital, the patient wears a gown and lies in a bed while doctors do rounds. In contrast, Diaz is invited to enter the patient’s home.
During an appointment with Petersen, Diaz commented on a scenic painting of ducks. The two discovered they both loved fishing and hunting and shared roots in northern Illinois.
Being in a patient’s home “humanizes the patient and the provider,” Diaz says. “It makes the ability to connect with a person that much easier, and it’s important clinically, determining a plan of care that will work in that context.”
The Benefits of Hospital at Home
In Sioux Falls, S.D., the nurses at Avera@Home, part of Avera McKinnan Hospital, agree that being in a patient’s home leads to better care and a more trusting relationship.
Cindy Kannenberg, nurse manager of the new Hospital at Home program offered by Avera@Home, says that rather than give patients a litany of discharge instructions from the hospital, “You can use their home environment…to find a way to help them learn how to take care of themselves better.”
“If you’re able to safely surround patients with care interventions, that will extend the capability of staying inside the home versus long-term care.”
A health practitioner might spot tripping hazards, say, or suggest ways to eat healthier.
Avera@Home expanded its traditional home care and hospice program in the wake of the pandemic. “We were taking care of a lot of patients in their homes during COVID,” says Rhonda Wiering, vice president, clinical growth and innovation. “Many were at home on oxygen and met the criteria to be in the hospital. The hospital saw that we could keep people safely at home.”
Avera is one of 77 medical systems and 177 hospitals in 33 states that have been approved for the federal government’s Centers for Medicare and Medicaid Services (CMS) waiver program to allow acute care in the home.
The Acute Hospital Care at Home program was created as part of the COVID-19 public health emergency. A newly-formed Advanced Care at Home Coalition, made up of major health systems such as the Mayo Clinic, Kaiser Permanente and Johns Hopkins, is advocating for CMS to make the waiver program permanent.
COVID-19 Accelerates the Move to Home-Based Care
Even before the pandemic, hospital-acquired infections were a serious, often deadly problem, with 687,000 cases in the U.S. in 2015, including 72,000 deaths. As COVID-19 filled beds, hospitals and patients alike were looking for alternatives.
Pioneered by Johns Hopkins University School of Medicine in 1995, Hospital at Home® demonstrated the model’s clinical and cost benefits, including decreased mortality and higher patient and caregiver satisfaction as a lower cost. Today, Hopkins Hospital At Home is offered through six Veterans Affairs Medical Centers and three hospitals.
“My experience not only with my parents but with others, they never return to baseline. This is my passion for having an alternative.”
Other researchers found similar results. A 2020 clinical trial in the Annals of Internal Medicine found that costs for treating acutely-ill patients at home were 38% lower compared to a hospitalized group. The in-home patients received fewer lab tests, radiology exams and specialist consultations, and they were less sedentary. Their readmission rates were also lower.
Not all patients are eligible for home care, such as those experiencing chest pain, stroke symptoms, severe abdominal pain or drug overdoses. Dozens of other common conditions, though, including congestive heart failure, urinary tract infections, shortness of breath and diarrhea can be treated at home.
Could At-Home Health Care Keep Folks Out of Nursing Homes?
Christi McCarren, senior vice president, retail health and community based care with MultiCare in Tacoma, Wash., became a convert to hospital at home after seeing her parents in their 90s struggle with hospital admissions.
“In short order, this population starts to decompensate and deteriorate in terms of their musculature and strength and endurance,” she says.
Each time her mother was admitted to a hospital, she was kept for three nights, which Medicare requires to cover care. She would then have a 30-day stay in a skilled nursing facility. “My experience not only with my parents but with others — they never return to baseline,” McCarren says. “This is my passion for having an alternative.”
Simply being in familiar surroundings, with loved ones and pets, can help older people weather a medical crisis, says McCarren. “They do better with much better outcomes,” she says. “I really believe this is where we need to go with our senior citizens.”
“The transitions to a facility, whether a hospital or an ER, tend to have negative impacts on their mental and physical health.”
To help patients avoid trips to urgent care or the emergency room, MultiCare partnered with Denver-based DispatchHealth. Two-person teams respond to calls from patients or providers. The team will either treat the patient at home or refer them to a higher level of care.
Kevin Riddleberger, cofounder of DispatchHealth, says the company has grown faster than it had projected when launching in 2013. It’s now in 40 markets in 20 states, serving hundreds of thousands of patients a year.
In addition to providing a spectrum of home care services, the company has carved out a “facility substitution” niche to keep people out of hospitals and skilled nursing facilities (SNF).
SNF substitution is a model of extended care for those transitioning out of the hospital. These people are provided care in their homes for up to 30 days. Although it does not replace long-term care in a nursing home, Riddleberger says, “If you’re able to safely surround patients with care interventions, that will extend the capability of staying inside the home versus long-term care.”
This may be especially beneficial for patients with dementia. “Keeping them in comfortable surroundings helps them,” he says. “The transitions to a facility, whether a hospital or an ER, tend to have negative impacts on their mental and physical health.”
DispatchHealth treats patients throughout the lifespan, including people who are on Medicaid and Medicare. “We treat individuals from all socio-economic means,” says Riddleberger. “None of this is self-pay or out-of-pocket.”
As technologies advance and as people age who are comfortable with computers and cell phones, home-based delivery of medical care is likely to grow, especially if CMS continues to fund acute care at home, say practitioners.
Already, remote patient monitoring devices allow providers to track a patient’s heart and breathing rate, weight changes and activity levels. Telemedicine, using video, is also improving, holding promise for those in rural areas who live far from a doctor (expanding broadband to such areas is included in the infrastructure bill that President Biden just signed into law).
“COVID has provided tailwinds to pushing care inside the home,” says Riddleberger. “The market is demanding it. [We can] do this more effectively, with a better [patient] experience and most importantly at a lower cost. Being able to provide an in-home level of care has the opportunity to save billions annually.”
Editor’s note: This story is part of The Future of Elder Care, a Next Avenue initiative with support from The John A. Hartford Foundation.
Beth Baker is a longtime journalist whose articles have appeared in the Washington Post, AARP Bulletin, and Ms. Magazine. She is the author of With a Little Help from Our Friends — Creating Community as We Grow Older and of Old Age in a New Age — The Promise of Transformative Nursing Homes. Read More